Pacific Soccer Camp Application Form Please print this completed Camp Application Form and post or fax together with your payment details to: Pacific Soccer, Po Box 239, Manly NSW 2095, (Australia) Phone: (02) 9977 2992 Fax: (02) 9977 0376 ABN: 98 056 624 492 Applicant Details: Name: Address: Suburb: Postcode: Contact No.: Age: Sex: M / F Club that you play for: Please Tick this box if your child requires Specialist Goalkeeping Coaching N.B. Goalkeeping coaching is only available at the Eastwood location with Outfield players. Camp Details: Date: 3.07.2006 to 7.07.2006 Day: Monday to Friday Time: 9.00 am to 1.00 pm Ages: For boys and girls aged 6-14 years Fee: $155 inc. GST (check group and family discounts) Please √ Camp you wish to attend: Canterbury Frenchs Forest Kirrawee Castle Hill Hunters Hill Mona Vale Caringbah Hurstville Pennant Hills Chatswood Kellyville Quakers Hill Eastwood Payment Details: (Please Tick) I enclose payment now by: Cheque Money Order Mastercard Bankcard Visa CARD NUMBER EXPIRY DATE CARD HOLDERS NAME: ______________________________________ AMOUNT: $ _____________________________________________ SIGNATURE: _______________________________________________ CONSENT FORM: I, the undersigned, approve of this application and in doing so do agree that the Pacific Soccer Camp and its officers and servants are free and clear of all responsibility whatsoever for any injury or illness that may occur during the applicants participation in the above mentioned activity. Data Protection Statement and Consent If you do not wish to receive any information about our services and products please tick this box Signature of Parent or Guardian:…………………………………. Date:………………………………….
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